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The future of anesthesiology

C

CremeSickle

    Tough

    Listen man, i understand and agree with 90% of what you are saying. The reason AAs wont work is b/c there are no anesthesiologist in the vast majority of these rural hospitals. The CRNAs work independently so an AA cannot legally replace them.

    As for the rural stipend. Lets be honest, its a drop in the bucket in an Anesthesiologists salary and isnt getting the average Joe to move to BFE. My graduating class had absolutely noone (except me) taking advantage of the VA/IHS incentives (or rural undeserved areas incentives) which pay back your entire loan for 2-5 years of service. Not having the stipend (which i think we should have equal access to) isnt the answer as the vast majority of physicians are not interested in living in rural areas regardless. Look at the Anesthesiologist demographic and its very clear we are clustered in the big "desirable" areas.

    You seem so CRNA-like. I could have sworn you were one. Regardless, why don't you answer my original question.

    Why would the hospital close if two capable AAs took over the CRNA jobs???
     

    EtherMD

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      Tough

      Listen man, i understand and agree with 90% of what you are saying. The reason AAs wont work is b/c there are no anesthesiologist in the vast majority of these rural hospitals. The CRNAs work independently so an AA cannot legally replace them.

      As for the rural stipend. Lets be honest, its a drop in the bucket in an Anesthesiologists salary and isnt getting the average Joe to move to BFE. My graduating class had absolutely noone (except me) taking advantage of the VA/IHS incentives (or rural undeserved areas incentives) which pay back your entire loan for 2-5 years of service. Not having the stipend (which i think we should have equal access to) isnt the answer as the vast majority of physicians are not interested in living in rural areas regardless. Look at the Anesthesiologist demographic and its very clear we are clustered in the big "desirable" areas.



      Toughlife, CRNA's are not going anywhere and there will be MORE of them in the field by the time you finish your Residency.

      Regardless of how you feel about Nurse Anesthetists they are a reality and are well-established in Anesthesia. Your comments serve no purpose are are pure "rhetoric" as they do not help the profession.

      Anesthesiologists are not going to stop the ACT model. AA's are welcome in the ACT model but there are only FOUR AA schools in existence. This compares with hundreds of CRNA training programs. Perhaps, twenty years from now AA's may make a "dent" in the Mid-Level Provider marketplace.
      But, this does not address the overall Anesthesia shortage which exists in the USA.

      My previous posts attempted to describe ways Program Directors, Chairpersons and the ABA could "boost" your stance in the hospital.

      I greatly resent your accussation that "I am hurting our profession" by staffing my hospital's operating room with Mid-Level providers. You clearly do not understand the economics of medicine, the manpower shortage in anesthesia and hospital politics. Instead, you attack the "messenger" with a vengeance because you do not like what you read. :scared:
       

      militarymd

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        ..... You clearly do not understand the economics of medicine, the manpower shortage in anesthesia and hospital politics. Instead, you attack the "messenger" with a vengeance because you do not like what you read. :scared:


        That is what most people don't understand.

        If all of the markets that require anesthesia services had 3rd party or any payers who are willing to and able to pay the going rate (80+ per unit), and the hospitals and surgeons agree to run the OR's efficiently (>70% utilization), then there would ONLY be MD models....

        However, reality is not what everyone wants it to be.....

        Unit reimbursement can be as low as 15 per unit (I'm not sure of the number, but somewhere around there).

        Some people can't pay.

        Optimal OR utilization may be sacrificed for cases in competition with Surgeon owned surgery centers.

        etc.
        etc.
        etc.

        For those of you in training spouting your rhetoric....save it.

        For those of you in markets that support all MD models.....good for you..you're very lucky.

        for those of you making money off physician extenders in good markets....watch your back.
         
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        UTSouthwestern

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          That is what most people don't understand.

          If all of the markets that require anesthesia services had 3rd party or any payers who are willing to and able to pay the going rate (80+ per unit), and the hospitals and surgeons agree to run the OR's efficiently (>70% utilization), then there would ONLY be MD models....

          However, reality is not what everyone wants it to be.....

          Unit reimbursement can be as low as 15 per unit (I'm not sure of the number, but somewhere around there).

          Some people can't pay.

          Optimal OR utilization may be sacrificed for cases in competition with Surgeon owned surgery centers.

          etc.
          etc.
          etc.

          For those of you in training spouting your rhetoric....save it.

          For those of you in markets that support all MD models.....good for you..you're very lucky.

          for those of you making money off physician extenders in good markets....watch your back.


          Unit reimbursement is as low as $11 in some states.

          For everyone worried about the future, stop talking and start doing.
           

          MDstudent79

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            I'm just a first-year, so I haven't had much exposure to the field of anesthesiology and don't know if I'd even be interested. BUT.... I'm wondering what can I take away from all of the talk above? In a nutshell?

            In other words, what exactly is the worry of some of the practicing anesthesiologists that are posting here? Is it that CRNAs will entirely REPLACE the MD's jobs? That CRNA salaries will increase such that they get too close to that of an MD? That MD anesthesiologist salaries will decrease significantly in the future (perhaps more than most specialties even)?

            I had thrown around the idea of anesthesiology in my mind before entering med school because it seemed fairly hands-on and like one would get a lot of exposure to many different surgical procedures. And the general nature of the work seemed appealing in some ways.

            But...I have to admit that my thoughts of anesthesiology have been a bit tainted with all the discussion on here. If nothing else, it just seems like there's an undue amount of angst and insecurity within those practicing in the field! Whether justified or not, it seems like an environment I'd rather not enter into.

            Here are some simple questions I have to those who have already contributed to this thread....

            1. Is the worry of the increasing power and encroachment of CRNAs due to the fact that CRNAs really CAN handle the job of most MD anesthesiologists? If they could not, why would this even be an issue? What are the stats on outcomes for CRNAs vs. MDs? Why is "too late" to prove that MDs have better results if they in fact do?

            2. Is it a problem if in the future MD anesthesiologists handled only more difficult surgeries, while CRNAs handled the easier cases? Is the main concern of this less compensation?

            3. My understanding is that CRNAs have been around for over a hundred years in this country and that within MDs, anesthesiology is a relatively young field. Is it possible that its necessity as a field was short-lived from the start and that technology has increased to the point that nearly all anesthesia CAN be administered by mid-level providers with little difficulty?

            4. In hospitals that are in locations to attract supervisory MD anesthesiologists, is it often that such MDs are turned away in factor of unsupervised CRNAs? Obviously, I understand such a case is necessary in many rural parts of the country, etc.

            5. What is the real harm if the CRNA's salaries increase due to their demand and level of expertise? Is it a feeling of "Why did I go to X years of schooling?" by current and near-future MD anesthesiologists?

            6. For you practicing MDs out there, would you recommend any first-year MD student even consider the field? If so, why?

            Just some questions I thought of while reading this thread. Thanks!
             

            dqbanrn

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              with the exception of those cases that present a unique challenge or difficlty, has surgical anesthesia evolved to the point that the training of an anesthesiologist is overkill for this particular task? It seems to me, with all the studies done on the subject, that crnas can handle most of the surigical anesthesia with the same success rate as an anesthesiologist. Where the crna training is defficient in comparrison to anesthesiologist is the areas concerning perioperative medicine, critical care and pain management. (not to mention the whole med school thing) Why dont anesthesiologist try to exploit their expertise in these areas? If crnas are providing similar outcomes in surgical anesthesia at a cheaper price, it will always be harder for an md to sell the same service at a higher cost, and the government tends to favor the lowest bidder.

              As you may guess, i am a nurse. i am currently finishing my masters in acute care, earning my ARNP in acute care. My school has a program for acute care graduates to gain direct entry to their CRNA school. i should be starting crna training in the spring of next year. my hospital is funding my education, with the understanding that i will be working for the anesthesia department when i finish. the anesthesia department manages the ICU in my hospital. The understanding is i will split my case load between the OR and patients in the ICU. This is not the first program ive seen take this approach. i have learned of a growing number of crna programs are favoring a masters in acute care from their applicants. this may be another sign that role of ICU training is expanding in anesthesia.
               

              EtherMD

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                with the exception of those cases that present a unique challenge or difficlty, has surgical anesthesia evolved to the point that the training of an anesthesiologist is overkill for this particular task? It seems to me, with all the studies done on the subject, that crnas can handle most of the surigical anesthesia with the same success rate as an anesthesiologist. Where the crna training is defficient in comparrison to anesthesiologist is the areas concerning perioperative medicine, critical care and pain management. (not to mention the whole med school thing) Why dont anesthesiologist try to exploit their expertise in these areas? If crnas are providing similar outcomes in surgical anesthesia at a cheaper price, it will always be harder for an md to sell the same service at a higher cost, and the government tends to favor the lowest bidder.

                As you may guess, i am a nurse. i am currently finishing my masters in acute care, earning my ARNP in acute care. My school has a program for acute care graduates to gain direct entry to their CRNA school. i should be starting crna training in the spring of next year. my hospital is funding my education, with the understanding that i will be working for the anesthesia department when i finish. the anesthesia department manages the ICU in my hospital. The understanding is i will split my case load between the OR and patients in the ICU. This is not the first program ive seen take this approach. i have learned of a growing number of crna programs are favoring a masters in acute care from their applicants. this may be another sign that role of ICU training is expanding in anesthesia.


                Good for you. While the role of PA's and ARNP's in the ICU setting in the ICU is extremely valuable and in demand it is very different from Anesthesia.

                PA's and ARNP's will never practice "solo" in an ICU. The patients are too sick and require the input of an Intensivist. As an ARNP in the ICU the Mid-Level role is well-maintained.

                This is not the case in Anesthesia. As a CRNA you have more "legal" rights and could earn significantly more money.

                ICU work is more demanding and more labor intensive. Recruiting PA's and ARNP's into this setting is difficult. Ironic though because most CRNA's get their start as ICU Nurses.
                 
                C

                CremeSickle

                  Midlevels in critical care.

                  Thats scary. Alot of PA programs are all of 24 months with no prior healthcare experience needed. Alot of NP programs now are direct BSN -> NP with no signifigant ICU experience before working as a midlevel.

                  No offence, these are not the people i want anything to do with patients who are very sick nor would I hire them for CCM.
                   

                  EtherMD

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                    I'm just a first-year, so I haven't had much exposure to the field of anesthesiology and don't know if I'd even be interested. BUT.... I'm wondering what can I take away from all of the talk above? In a nutshell?

                    In other words, what exactly is the worry of some of the practicing anesthesiologists that are posting here? Is it that CRNAs will entirely REPLACE the MD's jobs? That CRNA salaries will increase such that they get too close to that of an MD? That MD anesthesiologist salaries will decrease significantly in the future (perhaps more than most specialties even)?

                    I had thrown around the idea of anesthesiology in my mind before entering med school because it seemed fairly hands-on and like one would get a lot of exposure to many different surgical procedures. And the general nature of the work seemed appealing in some ways.

                    But...I have to admit that my thoughts of anesthesiology have been a bit tainted with all the discussion on here. If nothing else, it just seems like there's an undue amount of angst and insecurity within those practicing in the field! Whether justified or not, it seems like an environment I'd rather not enter into.

                    Here are some simple questions I have to those who have already contributed to this thread....

                    1. Is the worry of the increasing power and encroachment of CRNAs due to the fact that CRNAs really CAN handle the job of most MD anesthesiologists? If they could not, why would this even be an issue? What are the stats on outcomes for CRNAs vs. MDs? Why is "too late" to prove that MDs have better results if they in fact do?

                    2. Is it a problem if in the future MD anesthesiologists handled only more difficult surgeries, while CRNAs handled the easier cases? Is the main concern of this less compensation?

                    3. My understanding is that CRNAs have been around for over a hundred years in this country and that within MDs, anesthesiology is a relatively young field. Is it possible that its necessity as a field was short-lived from the start and that technology has increased to the point that nearly all anesthesia CAN be administered by mid-level providers with little difficulty?

                    4. In hospitals that are in locations to attract supervisory MD anesthesiologists, is it often that such MDs are turned away in factor of unsupervised CRNAs? Obviously, I understand such a case is necessary in many rural parts of the country, etc.

                    5. What is the real harm if the CRNA's salaries increase due to their demand and level of expertise? Is it a feeling of "Why did I go to X years of schooling?" by current and near-future MD anesthesiologists?

                    6. For you practicing MDs out there, would you recommend any first-year MD student even consider the field? If so, why?

                    Just some questions I thought of while reading this thread. Thanks!


                    Medicine as a whole is most likely to change a great deal in your lifetime. In fact, By the time you finish a Residency in your chosen specialty "Universal Health Care" will be a reality. The reason is because all the forces are finally agreeing some type of Universal Health in the USA is needed. Big Business, AARP, Democrats, Liberals and Republicans are all realizing the system is broken and needs a fix. All are willing to compromise to make some sort of Universal Care a reality.

                    So, my advice is to pick the area you like the most and hope for the best.
                    If you decide on Anesthesia I recommend an emphasis on Critical Care, Cardiac, Pediatrics or Pain Management. All these areas are "in-need" and enhance your ability to find employment after completion of your training. In fact, there are programs that will combine Critical Care and Cardiac into a combined 18 month fellowship. The advanced training will make you much more desireable for Hospitals and Groups.

                    In my opinion, major medical centers are not going to let CRNA's practice without an Anesthesiologist supervising the cases. But, the question remains that in the future how many CRNA's can one Anesthesiologist actually cover?
                    Thus, you want to "hedge your bets" by making sure you are well-qualified and subspecialized (formal) in your certification.
                     

                    cfdavid

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                      Medicine as a whole is most likely to change a great deal in your lifetime. In fact, By the time you finish a Residency in your chosen specialty "Universal Health Care" will be a reality. The reason is because all the forces are finally agreeing some type of Universal Health in the USA is needed. Big Business, AARP, Democrats, Liberals and Republicans are all realizing the system is broken and needs a fix. All are willing to compromise to make some sort of Universal Care a reality.

                      So, my advice is to pick the area you like the most and hope for the best.
                      If you decide on Anesthesia I recommend an emphasis on Critical Care, Cardiac, Pediatrics or Pain Management. All these areas are "in-need" and enhance your ability to find employment after completion of your training. In fact, there are programs that will combine Critical Care and Cardiac into a combined 18 month fellowship. The advanced training will make you much more desireable for Hospitals and Groups.

                      In my opinion, major medical centers are not going to let CRNA's practice without an Anesthesiologist supervising the cases. But, the question remains that in the future how many CRNA's can one Anesthesiologist actually cover?
                      Thus, you want to "hedge your bets" by making sure you are well-qualified and subspecialized (formal) in your certification.


                      Well stated. I'm interested in anesthesiology, as of now. But, I WILL force myself to do a fellowship regardless of the opportunity cost that has prevented others from doing so in the past. For me, in 8 years (OUCH!), the "opportunity cost" may not be as compelling, so perhaps it'll make the fellowship decision that much easier. I could see peds or cardiac as possible interests. I agree that it's an important hedge in the future, to further separate ourselves from the mid-level providers.
                       

                      drusso

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                        Medicine as a whole is most likely to change a great deal in your lifetime. In fact, By the time you finish a Residency in your chosen specialty "Universal Health Care" will be a reality. The reason is because all the forces are finally agreeing some type of Universal Health in the USA is needed. Big Business, AARP, Democrats, Liberals and Republicans are all realizing the system is broken and needs a fix. All are willing to compromise to make some sort of Universal Care a reality.

                        Here's a good article detailing the above from today's Washington Post:

                        http://www.washingtonpost.com/wp-dyn/content/article/2007/01/16/AR2007011601578.html
                         

                        UTSouthwestern

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                          Medicine as a whole is most likely to change a great deal in your lifetime. In fact, By the time you finish a Residency in your chosen specialty "Universal Health Care" will be a reality. The reason is because all the forces are finally agreeing some type of Universal Health in the USA is needed. Big Business, AARP, Democrats, Liberals and Republicans are all realizing the system is broken and needs a fix. All are willing to compromise to make some sort of Universal Care a reality.

                          I had a wonderful post that this stupid system just swallowed up.

                          In essence, the system isn't broken, it is abused over and over and over again.

                          When hospital systems, pharmaceutical giants, and insurance companies aren't raking in RECORD profits, then we can talk about a broken system.

                          It is a system that is being manipulated with the government left to pick up the pieces and it is a legal threat that keeps medicine practicing in an overly defensive and overly PC manner ("Yes please keep my brain dead spouse alive for more than a month for 2 or 3 million dollars.")

                          Indigent care is another discussion entirely (my vote is to charge the country of origin a fee for indigent health care or else take them back to get treatment).

                          Congress can start by doing a thorough and independ cost analysis of medical care and I can guarantee you that physician reimbursement will NOT be a major source of expenditures, and in any event, we lose money every year.

                          Look at what the biggest recipients of public and private funding are doing with those funds (see previous point about record profits) before trying to reinvent the wheel.
                           

                          cfdavid

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                            I had a wonderful post that this stupid system just swallowed up.

                            In essence, the system isn't broken, it is abused over and over and over again.

                            When hospital systems, pharmaceutical giants, and insurance companies aren't raking in RECORD profits, then we can talk about a broken system.

                            It is a system that is being manipulated with the government left to pick up the pieces and it is a legal threat that keeps medicine practicing in an overly defensive and overly PC manner ("Yes please keep my brain dead spouse alive for more than a month for 2 or 3 million dollars.")

                            Indigent care is another discussion entirely (my vote is to charge the country of origin a fee for indigent health care or else take them back to get treatment).

                            Congress can start by doing a thorough and independ cost analysis of medical care and I can guarantee you that physician reimbursement will NOT be a major source of expenditures, and in any event, we lose money every year.

                            Look at what the biggest recipients of public and private funding are doing with those funds (see previous point about record profits) before trying to reinvent the wheel.

                            The host government, in all of their compassion, would be grateful that we've made them aware of a medical treatment that one of their very own citizens is in need of, wouldn't they?? I'm on your side on this one. It's gonna really bog down our system, with major ill-effects if we don't get smart, and, heaven forbid I say it, tough.
                             
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                            toughlife

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                              All this talk about perioperative physicians... my perspective is quite limited but don't surgeons handle perioperative care? At least at my school, surgeons routinely rounded on/handled care for ICU patients.

                              JCAHO is now demanding that all ICUs, whether surgical or medical, be staffed with an intensivist who is fully dedicated to that particular unit. I had a chat about this yesterday with one of my attendings.

                              Surgeons are way too busy in the OR to be running the ICU. This new JCAHO rule will, on my opinion, spur the growth in ICU services in the future. Hopefully, the salaries will go along with it.

                              Also, I heard of a couple anesthesia attendings who did general anesthesia for one year and who went back for their fellowship at the same institution that employs them while receiving attending-level salary. From that perspective, it was a win-win situation for them. I wonder if there are more deals like that out there.

                              I would think that this would require some sort of time commitment but I am not privy to the details.
                               

                              EtherMD

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                                JCAHO is now demanding that all ICUs, whether surgical or medical, be staffed with an intensivist who is fully dedicated to that particular unit. I had a chat about this yesterday with one of my attendings.

                                Surgeons are way too busy to be in the OR to be running the ICU. This new JCAHO rule will, on my opinion, spur the growth in ICU services in the future. Hopefully, the salaries will go along with it.

                                Also, I heard of a couple anesthesia attendings who did general anesthesia for one year and who went back for their fellowship at the same institution that employs them while receiving attending-level salary. From that perspective, it was a win-win situation for them. I wonder if there are more deals like that out there.

                                I would think that this would require some sort of time commitment but I am not privy to the details.

                                Of course, you are correct about the time commitment. For example, the institution pays you $150,000 for your fellowship year. In return, you agree to be an Attending in the ICU and O.R. for the next three years. Your salary will be about $180-$200,000 for those three years. The institution gets a "quality" attending at a great price.

                                Now, check out this scenario. You "suck-it up" for one more year. You do a Critical Care fellowship with a one month elective in TEE and another in Bronchoscopy. When you finish most Groups will want you as a Cardiac Attending (even without TEE certification Intensivists are usually good Cardiac Attendings) and Intensivist. Your starting salary is $300-$350,000 and the next year $350-$400,000. Partnership is worth $500-$550,000. These are W-2 figures so you can add another $75,000 in benefits to those numbers.:D

                                Thus, you can definitely "cut a deal" to combine one year fellowship with a three commitment as an Attending.
                                 

                                Robert Loblaw

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                                  i'd be interested to hear thoughts from those attendings much closer to the economics of medicine as to what a universal coverage scheme may mean to physician salaries--my $250K in loans will be suffocating if I'm making primary care type money in 15 years, that's no friggin joke. not the least of which is the laughable idea that america in general would feel sorry for me if I only made $150K/year... might the threat of lower salaries finally produce a coherent physician lobby?
                                   

                                  juddson

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                                    When you finish most Groups will want you as a Cardiac Attending (even without TEE certification Intensivists are usually good Cardiac Attendings) and Intensivist. Your starting salary is $300-$350,000 and the next year $350-$400,000. Partnership is worth $500-$550,000. These are W-2 figures so you can add another $75,000 in benefits to those numbers.:D

                                    .

                                    You mean an attending in the cardiac intensive care unit?

                                    Judd
                                     

                                    fakin' the funk

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                                      JCAHO is now demanding that all ICUs, whether surgical or medical, be staffed with an intensivist who is fully dedicated to that particular unit. I had a chat about this yesterday with one of my attendings.

                                      Does this preserve the way some anesthesiologists practice, a month = 1 wk fulltime ICU/3 wks fulltime OR?
                                       

                                      toughlife

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                                        so which CC fellowships are teaching TEE and Bronchoscopy?

                                        I looked on freida at a couple programs and did see any mention of these. I also know we are not doing this at IU.

                                        apellous

                                        Each fellowship gives you a certain # of months (2-3) during which you could arrange for TEE/Bronch time provided the institution offers them as electives.
                                         
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                                        EtherMD

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                                          so which CC fellowships are teaching TEE and Bronchoscopy?

                                          I looked on freida at a couple programs and did see any mention of these. I also know we are not doing this at IU.

                                          apellous

                                          The responses to my posts show I must be very specific in my comments. When I stated Intensivists are usually good Cardiac Attendings I am refering to high risk CV Surgery in the Operating Room. Of course, an ICU Intensivist can cover the CCU, SICU, MICU, etc. But, in addition to the ICU a Critical Care attending SHOULD be able to Anesthetize the sickest adult patients including Cardiac Cases.

                                          Some Critical Care Fellowships allow 'elective' time in TEE and/or bronchoscopy. These are valuable in the real world and enhance your "dollar skills" greatly. The ability to do these electives in your fellowship should be a major factor in where you spend those 12 months.

                                          As for where our salaries will be in ten years I am predicting a 30% decrease from Today. All the more reason for one to be "extremely valuable" after Residency and have formal skils beyond the average Anesthesiologist (TEE certification, Critical Care Certification, Pain Management or complicated Pediatrics). Those that have these advanced skills enjoy an advantage in the marketplace. As the number of high paying positions available begin to dwindle those that have one of the above mentioned advantages have a huge "leg-up" on those that don't.
                                           

                                          EtherMD

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                                            i'd be interested to hear thoughts from those attendings much closer to the economics of medicine as to what a universal coverage scheme may mean to physician salaries--my $250K in loans will be suffocating if I'm making primary care type money in 15 years, that's no friggin joke. not the least of which is the laughable idea that america in general would feel sorry for me if I only made $150K/year... might the threat of lower salaries finally produce a coherent physician lobby?


                                            I really can relate to your situation. When I finsished Residency I owed $70,000 in student loans. I had to borrow $5,000 from a Bank to take my Boards and move to my new job. I thought soon I will be "rolling in dough" making $100,000 then $125,000 per year. In short, I was clueless to what it took to live "nicely" in the real world. By the time I paid all my taxes, my student loan payments, my new loan payment, my rent on the apartment, car payment, etc. I had little left. It took me three years to buy my first home and two years as partner to pay off all my student loans. It is a lot easier spending or borrowing money than saving it.

                                            With your kind of loans you will need at least $350-$400,000 for a few years to get out of the "hole." This is why I recommend one year of additional slavery called fellowship for you. It will give you the "leg-up" on the competition. High paying jobs (greater than $500,000) are harder to find and land. With a fellowship at a good program your chances are much better at getting this type of job. Remember, that $500,000 job may be down to $400,000 by the time you finish your training and the partnership track.
                                             

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                                              I really can relate to your situation. When I finsished Residency I owed $70,000 in student loans. I had to borrow $5,000 from a Bank to take my Boards and move to my new job. I thought soon I will be "rolling in dough" making $100,000 then $125,000 per year. In short, I was clueless to what it took to live "nicely" in the real world. By the time I paid all my taxes, my student loan payments, my new loan payment, my rent on the apartment, car payment, etc. I had little left. It took me three years to buy my first home and two years as partner to pay off all my student loans. It is a lot easier spending or borrowing money than saving it.

                                              With your kind of loans you will need at least $350-$400,000 for a few years to get out of the "hole." This is why I recommend one year of additional slavery called fellowship for you. It will give you the "leg-up" on the competition. High paying jobs (greater than $500,000) are harder to find and land. With a fellowship at a good program your chances are much better at getting this type of job. Remember, that $500,000 job may be down to $400,000 by the time you finish your training and the partnership track.

                                              i'm a first year med student. i am planning anesthesiology + ccm + cardiac fellowships, so i'll be done in about 10 years. i've had lots of time to think this stuff over, so i don't have to be lectured on how i need to experience other fields, etc. bottom line is i'm going to med school for the above purpose. several of the experienced attendings here have said that presently there are very few private practice groups that offer a mix of both icu + OR work, and i'm wondering if it's going to change within the next 10 years (and beyond) because of JCAHO and the leapfrog initiative. any input would be great. i really cannot see myself doing anything else (and being happy).
                                               

                                              EtherMD

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                                                i'm a first year med student. i am planning anesthesiology + ccm + cardiac fellowships, so i'll be done in about 10 years. i've had lots of time to think this stuff over, so i don't have to be lectured on how i need to experience other fields, etc. bottom line is i'm going to med school for the above purpose. several of the experienced attendings here have said that presently there are very few private practice groups that offer a mix of both icu + OR work, and i'm wondering if it's going to change within the next 10 years (and beyond) because of JCAHO and the leapfrog initiative. any input would be great. i really cannot see myself doing anything else (and being happy).

                                                The specialty of Anesthesiology will always need good, dedicated people.
                                                I am not trying to "lecture you" on why you shouldn't choose Anesthesiology.
                                                Instead, I am trying to explain the positives and negatives of the specialty.
                                                Also, the value of additional formal training beyond "basic anesthesia."

                                                There are Groups that cover the Operating Rooms and ICU. I know of at least three large, financial successful, Private Practice Groups that have Critical Care Certified Anesthesiologists as an integral part of the practice.
                                                The hospitals usually provide a large "stipend" for the ICU coverage. In addition, Intensive Care Anesthesiologists rotate in the Operating Room and take call.

                                                But, you are a first year Medical Student. Why close your mind to other specialties like Cardiology? Internal Medicine offers Critical Care certification as well Pulmonary Medicine. If your interest is PRIMARILY Critical Care then why choose Anesthesiology without considering the others? That said, the role of Intensivisits in hospitals across the USA is only going to increase over the next ten years. You will never lack job security with Anesthesiology plus fellowships in Critical Care Medicine and Cardiac Anesthesia.

                                                If you were to only pick one fellowship which one would you choose? I ask that question because in today's economic climate Cardiac Anesthesia with Certification in TEE would get you more job offers in the top 10% pay range.
                                                Critical Care Certification is valuable and would get you fewer offers right our of training. However, ten years from now things will be very different and I could easily see Critical Care being the more "valuable" fellowship. One more thing: The "burn-out" factor is higher in Critical Care than Cardiac/Basic Aneshesia in the operating room. Another reason you want to be "cross-trained" in other areas.
                                                 

                                                markneil

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                                                  The specialty of Anesthesiology will always need good, dedicated people.
                                                  I am not trying to "lecture you" on why you shouldn't choose Anesthesiology.
                                                  Instead, I am trying to explain the positives and negatives of the specialty.
                                                  Also, the value of additional formal training beyond "basic anesthesia."

                                                  There are Groups that cover the Operating Rooms and ICU. I know of at least three large, financial successful, Private Practice Groups that have Critical Care Certified Anesthesiologists as an integral part of the practice.
                                                  The hospitals usually provide a large "stipend" for the ICU coverage. In addition, Intensive Care Anesthesiologists rotate in the Operating Room and take call.

                                                  But, you are a first year Medical Student. Why close your mind to other specialties like Cardiology? Internal Medicine offers Critical Care certification as well Pulmonary Medicine. If your interest is PRIMARILY Critical Care then why choose Anesthesiology without considering the others? That said, the role of Intensivisits in hospitals across the USA is only going to increase over the next ten years. You will never lack job security with Anesthesiology plus fellowships in Critical Care Medicine and Cardiac Anesthesia.

                                                  If you were to only pick one fellowship which one would you choose? I ask that question because in today's economic climate Cardiac Anesthesia with Certification in TEE would get you more job offers in the top 10% pay range.
                                                  Critical Care Certification is valuable and would get you fewer offers right our of training. However, ten years from now things will be very different and I could easily see Critical Care being the more "valuable" fellowship. One more thing: The "burn-out" factor is higher in Critical Care than Cardiac/Basic Aneshesia in the operating room. Another reason you want to be "cross-trained" in other areas.

                                                  thanks for the input. i would rather choose critical care if given the option. im + pulm/ccm does not appeal to me since i would rather spend my time in the OR than the sleep center, clinic, or golf course. i like long nights/days and long vacations. i'm not counting out any other specialty, although they'd have to blow my mind in order for me to change.
                                                   

                                                  toughlife

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                                                    The specialty of Anesthesiology will always need good, dedicated people.
                                                    I am not trying to "lecture you" on why you shouldn't choose Anesthesiology.
                                                    Instead, I am trying to explain the positives and negatives of the specialty.
                                                    Also, the value of additional formal training beyond "basic anesthesia."

                                                    There are Groups that cover the Operating Rooms and ICU. I know of at least three large, financial successful, Private Practice Groups that have Critical Care Certified Anesthesiologists as an integral part of the practice.
                                                    The hospitals usually provide a large "stipend" for the ICU coverage. In addition, Intensive Care Anesthesiologists rotate in the Operating Room and take call.

                                                    That idea sounds good. I hope future trends in private practice groups resemble this scenario. What better way of demonstrating to the hospital and administrators that anesthesiologists are an integral part of patient care (compared to others) than to be seen as the ICU pimps. I would of course expect the hospital to cough up some coin for those services, but I'd be glad to provide them.

                                                    If you were to only pick one fellowship which one would you choose? I ask that question because in today's economic climate Cardiac Anesthesia with Certification in TEE would get you more job offers in the top 10% pay range.
                                                    Critical Care Certification is valuable and would get you fewer offers right our of training. However, ten years from now things will be very different and I could easily see Critical Care being the more "valuable" fellowship. One more thing: The "burn-out" factor is higher in Critical Care than Cardiac/Basic Aneshesia in the operating room. Another reason you want to be "cross-trained" in other areas.

                                                    Someone mentioned the possibility of a combined 18-month fellowship where ICU and CT anesthesia certification could be attained. Can we start a list of places that offer fellowships for anesthesia residents that may be attractive to a few of us here
                                                     

                                                    markneil

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                                                      Someone mentioned the possibility of a combined 18-month fellowship where ICU and CT anesthesia certification could be attained. Can we start a list of places that offer fellowships for anesthesia residents that may be attractive to a few of us here

                                                      one school i know: wustl -- offers the ccm + cardiac fellowship.
                                                       

                                                      juddson

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                                                        Can someone discuss the various practice and compensation models for anesthesia. Such as private practice versus hospital employee; solo versus group. How are anesthesiologists compensated? How so in the OR as opposed to the ICU? Include things like stipends from hospitals. How do these work?

                                                        Thanks
                                                        Judd
                                                         
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                                                        EtherMD

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                                                          Can someone discuss the various practice and compensation models for anesthesia. Such as private practice versus hospital employee; solo versus group. How are anesthesiologists compensated? How so in the OR as opposed to the ICU? Include things like stipends from hospitals. How do these work?

                                                          Thanks
                                                          Judd

                                                          Judd,

                                                          As a Medical Student compensation is likely to change dramatically before you finsh Medical School and Residency (plus fellowship). Are you at least SEVEN years away from worrying about compensation? Don't you realize that seven years ago my compensation model was not the same as it is today.

                                                          Basically, Anesthesiologists in Private practice have many different compensation models depending on the payer mix of the area. If many patients have NO INSURANCE or MEDICAID than a hospital salary or "stipend" to boost income is required. However, if your payer mix is "good" then straight "fee for service" billing is all that is required to make a nice living.
                                                          Currently, about 80% of Groups/Practices receive some financial support from the hospital for services.

                                                          Let me summarize:

                                                          1. No Support from the hospital- "You eat what you kill" or collect from Insurance carriers and Medicare. This is about 20% of Practices or Groups.
                                                          Anesthesiologists who work on their own (without a Group) often fall into this category.

                                                          2. Subsidy Model- The hospital pays the Group a certain amount of money per year for providing services to the hospital. This can done directly by paying a monthly amount to the Group or by paying a blended unit for all cases done at the hospital. ICU coverage is supported with money from the hospital or income guarantee model. Most hospitals pay something for OB coverage, Trauma coverage, etc.

                                                          3. Employee Model- Some hospitals employ the CRNA's in order to save the Group money. THe hospital and Group then split the revenue. Since the CRNA costs a great deal this results in a subsidy model. The hospital can control costs by keeping the number of CRNA's in check. This model does not work well. Also, hospitals can employ Anesthesiologists directly as well as the CRNA's. More hospitals may go this route in the future but administrators make lousy Anesthesia management/anesthesia directors.
                                                          The employee model by the hospital is ineffecient and usually lacks "incentive" for productivity from the anesthesia provider.

                                                          4. Management Company- This is the model many hospitals are turning to recently for Anesthesia Services. The hospital hires an Anesthesia Management company to run their department. The company getsa piece of the pie and bills the hospital for services. The hospital guarantees the company a "minimum amount of revenue" for a certain amount of services.
                                                          A list of these companies include Sheridan, NAPA, Millenium, etc. Anesthesiologists salaries are "reduced" with this model because the management company "skims" a nice percentage off the top.
                                                          In my area, Groups are responding to the management company by agreeing to provide more services for less money. I guarantee my hospital to provide MORE services for at least 10% less than ANY management company.
                                                          This strategy has worked so far and allowed the Group (both CRNA and MD)
                                                          to do well.

                                                          Nothing prevents hospitals from combining models in order to create an arrangement satisfactory for both parties. I predict more Management Companies and direct employment in the future.:eek:
                                                           

                                                          juddson

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                                                            4. Management Company- This is the model many hospitals are turning to recently for Anesthesia Services. The hospital hires an Anesthesia Management company to run their department. The company getsa piece of the pie and bills the hospital for services. The hospital guarantees the company a "minimum amount of revenue" for a certain amount of services.
                                                            A list of these companies include Sheridan, NAPA, Millenium, etc. Anesthesiologists salaries are "reduced" with this model because the management company "skims" a nice percentage off the top.
                                                            In my area, Groups are responding to the management company by agreeing to provide more services for less money. I guarantee my hospital to provide MORE services for at least 10% less than ANY management company.
                                                            This strategy has worked so far and allowed the Group (both CRNA and MD)
                                                            to do well.

                                                            Nothing prevents hospitals from combining models in order to create an arrangement satisfactory for both parties. I predict more Management Companies and direct employment in the future.:eek:

                                                            This model strikes me as inefficient as it artificially introduces a middle-man into the revenue stream. Why would this model portend the future of anesthesiology practice? As I presently understand the "Management Company" model (from reading your posts) the management companies hire MD's and CRNA's, sends them to work for hospitals, collects the revenue and pays a salary. How does a group MD practice (which also hires CRNA's and junior MD's)) differ from this model? Only in that MD's own the group practice and participate in profits rather than collect a guaranteed salary? If this is the case, it seems to me that these are just two anesthesia provider groups competing in the marketplace for anesthesia work, no?

                                                            Or, is it that anesthesia groups contract with management companies to find them work? Given abundance of gas work, this would seem stupid to me.

                                                            Am I confused?

                                                            Judd
                                                             

                                                            militarymd

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                                                              BTW, who owns these management companies? MD's? CRNA's? Non-healthcare providers?

                                                              Judd

                                                              all of the above.....

                                                              as to why hospitals go to AMCs?

                                                              We had invited a management company's CEO to come to town yesterday to discuss something unrelated to anesthesia....but him and I started talking about the success of AMCs....

                                                              According to him...the reason why AMC's thrive is because:

                                                              1) anesthesiologists think too highy about themselves...and their training and skills.

                                                              2) fail to recognize that ...although we're doctors....we are just a widget providing a service that is fee based.

                                                              3) fail to recognize that we are all replaceable.

                                                              He said the above mentality leads to stagnation...poor service...poor hospital and surgeon satisfaction....which then leads the administration to go to AMCs.

                                                              Believe it or not....the administration doesn't care how "good" you are at being an anesthesiologist...they care about "other" things that AMC's are good at providing.
                                                               

                                                              juddson

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                                                                all of the above.....

                                                                as to why hospitals go to AMCs?

                                                                We had invited a management company's CEO to come to town yesterday to discuss something unrelated to anesthesia....but him and I started talking about the success of AMCs....

                                                                According to him...the reason why AMC's thrive is because:

                                                                1) anesthesiologists think too highy about themselves...and their training and skills.

                                                                2) fail to recognize that ...although we're doctors....we are just a widget providing a service that is fee based.

                                                                3) fail to recognize that we are all replaceable.

                                                                He said the above mentality leads to stagnation...poor service...poor hospital and surgeon satisfaction....which then leads the administration to go to AMCs.

                                                                Believe it or not....the administration doesn't care how "good" you are at being an anesthesiologist...they care about "other" things that AMC's are good at providing.

                                                                None of this makes any sense to me. The people who work for management companies are, among others, MD's - the very same MD's who would be providing this "sub-par" care where they not working for the management companies.

                                                                These management companies could do NOTHING without MD's (and CRNA's) willing to castrate themselves for . . . what, I'm not sure. This just gets better and better.

                                                                Judd
                                                                 

                                                                militarymd

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                                                                  Believe it or not....the administration doesn't care how "good" you are at being an anesthesiologist...they care about "other" things that AMC's are good at providing.

                                                                  None of this makes any sense to me. The people who work for management companies are, among others, MD's - the very same MD's who would be providing this "sub-par" care where they not working for the management companies.

                                                                  These management companies could do NOTHING without MD's (and CRNA's) willing to castrate themselves for . . . what, I'm not sure. This just gets better and better.

                                                                  Judd
                                                                  x
                                                                   

                                                                  toughlife

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                                                                    None of this makes any sense to me. The people who work for management companies are, among others, MD's - the very same MD's who would be providing this "sub-par" care where they not working for the management companies.

                                                                    These management companies could do NOTHING without MD's (and CRNA's) willing to castrate themselves for . . . what, I'm not sure. This just gets better and better.

                                                                    Judd


                                                                    I think AMCs have wide networks that would allow them to move and reallocate physicians from one part of the country to another. So they are not necessarily obligated to hire the same 'subpar' physicians.

                                                                    Did you read the article on a prior post about AMCs in emergency medicine? This idea was described there and explained how physicians would be 'assigned' to different states. With the willingness of some to do locum tenems this is feasible idea.

                                                                    The bottom line is that a hospital wants a service provided at a good value.
                                                                    If you think about it, we are no different. Every 6 months I am on the phone with the cable/internet company threatening them about going with their competitor if they don't give me a discount/add more channels to my internet/cable TV package. I always use the "I am going with Direct TV" line and they always keep extending the discount for 'another six months'.

                                                                    Same principle applies to the hospital. It's all about value and 'customer service'. Heck even the multimillion dollar corporations like car rental companies, airlines, etc follow this same principle. They have lots of $$$ but in the end they provide a service.

                                                                    Think of medicine as a service profession and it will make more sense.
                                                                     

                                                                    juddson

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                                                                      I think AMCs have wide networks that would allow them to move and reallocate physicians from one part of the country to another. So they are not necessarily obligated to hire the same 'subpar' physicians.

                                                                      Did you read the article on a prior post about AMCs in emergency medicine? This idea was described there and explained how physicians would be 'assigned' to different states. With the willingness of some to do locum tenems this is feasible idea.

                                                                      The bottom line is that a hospital wants a service provided at a good value.
                                                                      If you think about it, we are no different. Every 6 months I am on the phone with the cable/internet company threatening them about going with their competitor if they don't give me a discount/add more channels to my internet/cable TV package. I always use the "I am going with Direct TV" line and they always keep extending the discount for 'another six months'.

                                                                      Same principle applies to the hospital. It's all about value and 'customer service'. Heck even the multimillion dollar corporations like car rental companies, airlines, etc follow this same principle. They have lots of $$$ but in the end they provide a service.

                                                                      Think of medicine as a service profession and it will make more sense.


                                                                      yes yes, I get all of that. What I don't get is how these companies can offer better service for less money than the local, independent groups unless, of course, the MD's who work for these groups are willing to earn less money and move all over the country to do it. I supposed this is possible (after all, pathologists who work for Ameripath, etc., do just that). But it devalues the services of an anesthesiologist, not the other way around. After all, generally locum work is less desireable than full-time perm work, no? Those MD's who choose to work for these companies debase the entire profession by vesting their livelihood with people who know little medicine and whose interests are not at all alligned with the MD's.

                                                                      I see this over and over again in almost every field of medicine - MD's, who possess ALL of the medical knowledge and therefore hold an absolute veto on the provision of healthcare in the United States are voluntarily ceding the sine quo non of "professionalism" - the ability to participate in the revenues and profits of ones skilled labor - to those whose interests are not nearly alligned. WTF!!!!???

                                                                      Judd
                                                                       

                                                                      militarymd

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                                                                        .......and whose interests are not at all alligned with the MD's.

                                                                        ...... WTF!!!!???

                                                                        Judd


                                                                        god forbid.....alignment of interest that is NOT with the MD's....:eek:

                                                                        but in improving service for the patient...:eek:

                                                                        Blasphemy....we should lynch anyone who thinks about an alignment other than with the Almighty doctor.
                                                                         

                                                                        johankriek

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                                                                          all of the above.....

                                                                          ....the administration doesn't care how "good" you are at being an anesthesiologist....

                                                                          they will start caring after the first few anesthesia mishaps.. namely brain death in a parturient or a pedi outright death.....

                                                                          I can bet you everything i have in the bank they will start caring then...
                                                                           

                                                                          EtherMD

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                                                                            yes yes, I get all of that. What I don't get is how these companies can offer better service for less money than the local, independent groups unless, of course, the MD's who work for these groups are willing to earn less money and move all over the country to do it. I supposed this is possible (after all, pathologists who work for Ameripath, etc., do just that). But it devalues the services of an anesthesiologist, not the other way around. After all, generally locum work is less desireable than full-time perm work, no? Those MD's who choose to work for these companies debase the entire profession by vesting their livelihood with people who know little medicine and whose interests are not at all alligned with the MD's.

                                                                            I see this over and over again in almost every field of medicine - MD's, who possess ALL of the medical knowledge and therefore hold an absolute veto on the provision of healthcare in the United States are voluntarily ceding the sine quo non of "professionalism" - the ability to participate in the revenues and profits of ones skilled labor - to those whose interests are not nearly alligned. WTF!!!!???

                                                                            Judd


                                                                            Judd,

                                                                            The key to winning the game against the management companies is not being arrogant and admitting you provide a service that is replaceable. In other words, drop the attitude about being the "best" and "most qualified" and use your business skills and Medical Staff Relationships to win this game.

                                                                            For example, the Management company will do it for "X" amount of money.
                                                                            I will do it for 10% less than "X" with a THREE year guarantee on costs.
                                                                            If you do your job well (get along with the surgeons, don't cancel many cases and do the add-ons) the administration will pick you. But, if you don't answer your beeper, cancel a lot of cases, won't provide coverage at night and on the weekends for semi-elective cases (very few real emergencies exist) then you will be replaced.

                                                                            This is why you hire and retain FIRST RATE individuals and keep enough MId-Level Providers avail. to cover all the cases during the day and at night. In short, you run a good business and that business is service plus availability.
                                                                            The surgeons notice when you go the extra mile to help them and when you are in-house 24/7. The irony is that the management company can actually help you get more money from the hospital. By having these companies bid on the SAME LEVEL of service provided by a Group places a "dollar figure" on the work. Without the layer of MBA "bi#*hes getting their piece of the action THERE IS NO WAY YOU CAN NOT COMPETE with them. Another reason why Anesthesiologists must be active on committees and with administration. The more you interact well with your colleagues on the Medical Staff the more likely you will keep your job.

                                                                            However, you will not be able to be "lazy" and "gouge" the hospital. Now, everyone must work hard and pitch-in to make the project work. One last thing, the hospital MBA will expect you to beat the management company bid since you are just a "Physician" and have less expenses. Again, NO PROBLEM if you hire and retain FIRST TIER people. The days of the fat, lazy "senior" partner who works 6 hours a day and takes NO CALL are over!:)
                                                                             

                                                                            militarymd

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                                                                              all of the above.....

                                                                              as to why hospitals go to AMCs?

                                                                              We had invited a management company's CEO to come to town yesterday to discuss something unrelated to anesthesia....but him and I started talking about the success of AMCs....

                                                                              According to him...the reason why AMC's thrive is because:

                                                                              1) anesthesiologists think too highy about themselves...and their training and skills.

                                                                              2) fail to recognize that ...although we're doctors....we are just a widget providing a service that is fee based.

                                                                              3) fail to recognize that we are all replaceable.

                                                                              He said the above mentality leads to stagnation...poor service...poor hospital and surgeon satisfaction....which then leads the administration to go to AMCs.

                                                                              Believe it or not....the administration doesn't care how "good" you are at being an anesthesiologist...they care about "other" things that AMC's are good at providing.

                                                                              Judd,

                                                                              The key to winning the game against the management companies is not being arrogant and admitting you provide a service that is replaceable. In other words, drop the attitude about being the "best" and "most qualified" and use your business skills and Medical Staff Relationships to win this game.

                                                                              For example, the Management company will do it for "X" amount of money.
                                                                              I will do it for 10% less than "X" with a THREE year guarantee on costs.
                                                                              If you do your job well (get along with the surgeons, don't cancel many cases and do the add-ons) the administration will pick you. But, if you don't answer your beeper, cancel a lot of cases, won't provide coverage at night and on the weekends for semi-elective cases (very few real emergencies exist) then you will be replaced.

                                                                              This is why you hire and retain FIRST RATE individuals and keep enough MId-Level Providers avail. to cover all the cases during the day and at night. In short, you run a good business and that business is service plus availability.
                                                                              The surgeons notice when you go the extra mile to help them and when you are in-house 24/7. The irony is that the management company can actually help you get more money from the hospital. By having these companies bid on the SAME LEVEL of service provided by a Group places a "dollar figure" on the work. Without the layer of MBA "bi#*hes getting their piece of the action THERE IS NO WAY YOU CAN NOT COMPETE with them. Another reason why Anesthesiologists must be active on committees and with administration. The more you interact well with your colleagues on the Medical Staff the more likely you will keep your job.

                                                                              However, you will not be able to be "lazy" and "gouge" the hospital. Now, everyone must work hard and pitch-in to make the project work. One last thing, the hospital MBA will expect you to beat the management company bid since you are just a "Physician" and have less expenses. Again, NO PROBLEM if you hire and retain FIRST TIER people. The days of the fat, lazy "senior" partner who works 6 hours a day and takes NO CALL are over!:)

                                                                              ether gave it to you straight.....

                                                                              I gave it to you like a smartass.
                                                                               

                                                                              juddson

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                                                                                god forbid.....alignment of interest that is NOT with the MD's....:eek:

                                                                                but in improving service for the patient...:eek:

                                                                                Blasphemy....we should lynch anyone who thinks about an alignment other than with the Almighty doctor.

                                                                                I'm talking about doctor's interests. I make no bones about it. The premise of my entire posts is questioning why doctors would willingly chop their legs off for people who don't have their interests at heart. The answer is NOT that it is for the betterment of the patient. I'll stipulate that each model offers identical patient care and outcomes (and refuse to stipulate that one model is better for the patient than the other).

                                                                                None of this has a god damned thing to do with what is best for the patient. It's money. So let's talk interests.

                                                                                Judd
                                                                                 

                                                                                juddson

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                                                                                  Judd,

                                                                                  The key to winning the game against the management companies is not being arrogant and admitting you provide a service that is replaceable. In other words, drop the attitude about being the "best" and "most qualified" and use your business skills and Medical Staff Relationships to win this game.

                                                                                  Bill$****!!!!! The argument I'm making here is NOT that the MD's provide better care (I suspect that in most cases, the MD is over-trained to handle most intraoperative anesthesia anyway). My point is ONLY that the MD's are the ones responsible for training and educating all of the mid-level providers, and therefore when push comes to shove the MD's are ABSOLUTELY NOT forced into these market-driven relationships. MD's have a weapon that they are loathe to recognize. Why they keep it quivered is quite beyond me.

                                                                                  For example, the Management company will do it for "X" amount of money.
                                                                                  I will do it for 10% less than "X" with a THREE year guarantee on costs.
                                                                                  If you do your job well (get along with the surgeons, don't cancel many cases and do the add-ons) the administration will pick you. But, if you don't answer your beeper, cancel a lot of cases, won't provide coverage at night and on the weekends for semi-elective cases (very few real emergencies exist) then you will be replaced.

                                                                                  That's fine. But what you are intimating is that MD anesthesia has become lazy and entitled. To the extent that is true, they deserve to be replaced by people (whoever they are) that are willing to do the work they are unwilling to do. Is that the explanation for why these management companies are able to make headway into the marketplace? I can't see why a private MD group can't police itself just as well as effectivley as a corporate MD group can. That they are not is one issue. That they are incapable is quite another.

                                                                                  This is why you hire and retain FIRST RATE individuals and keep enough MId-Level Providers avail. to cover all the cases during the day and at night. In short, you run a good business and that business is service plus availability.
                                                                                  The surgeons notice when you go the extra mile to help them and when you are in-house 24/7. The irony is that the management company can actually help you get more money from the hospital. By having these companies bid on the SAME LEVEL of service provided by a Group places a "dollar figure" on the work. Without the layer of MBA "bi#*hes getting their piece of the action THERE IS NO WAY YOU CAN NOT COMPETE with them.

                                                                                  Well, this gets back the question I originally asked you - if the corporations are unable to provide an equal for better service for the same or less amount of money, they have no shot in the marketplace. I wondered then how they could possibly compete if they have (essentially) introduced another level of revenue skim between the hospital and the anesthesiologist. You can crystalize this whole issue by writing here whether or not your contracts with the hospitals have been more favorable or less favorable since the management companies have started to bid. If they are less favorable (which I gather they have been otherwise this whole issue would not warrant an entire thread), the question is "why". One answer is that the management companies could, despite the extra layer of profit-takers, provide a better or same service for less money (presumably by paying their staff much less money). If that is the case, then I am back to my original question - who are these MD's willing to earn so much less money? They are either stupid or bottom or the barrel? They don't do it out of the goodness of their heart.

                                                                                  I'll say something else as well about this as well - my understanding of the management company model suggests to me that they hire more transient, locum, temp . . . whatever, sort of people to staff the OR's and ICU's. You might describe them as anything you like, but "top teir" is not one of them. Top teir people are not willing to work for less money.

                                                                                  The last bit about the hospital MBA agreeing to pay the management company more simply because it has greater top-down expenses is ridiculous. MBA's don't make these sorts of allowances. You pay for service and results.

                                                                                  Judd
                                                                                   

                                                                                  johankriek

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                                                                                    Im so sick of hearing that im overtrained to take care of patients who are NOT asa 4.5 e patients. Am i supposed to be sweating my ass off through out the whole case cardioverting patients every 15 minutes intra op for me to be put to good use.. I mean dont get me wrong I absolutely dont have a problem with tackling difficult cases but Im certainly not over trained. Why do you think the length of training was increased to 4 years just 10 years ago and there is talk of making it one more year.. That wouldnt be the case if I was over trained..

                                                                                    I am an independent contractor.. If i was looking for a job it certainly would NOT be a partnership track job witha private MD group. I would much rather work for an anesthesia management group.. At least you are not seeing the people who are screwing you on a daily basis.... and they pay more..... but i would never go either..

                                                                                    Military md you are whats wrong with the profession..
                                                                                     
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